Including organisational, communication, training, work environment, design and personal factors, and their resulting positive or negative impacts on safety.


Safety Culture

Positive: In an organisation with a positive culture the senior leadership creates a ‘just culture’ in preference to ‘blaming and shaming’. Staff feel confident to report patient safety incidents and   lessons are learned and shared to help prevent future harm.

Negative: In an organisation with a negative culture the senior management prioritizes targets and efficiency savings over safety. Staff may feel pressure to take risks and commit violations (‘take short cuts’).


Positive: A senior manager regular visits wards. She gathers information from her observations and from frontline staff about the levels of safety in her organisation.  She uses her information to help design and implement appropriate improvement interventions.

Negative:  A manager implements an improvement initiative in a ‘top down’ manner, without any consultation with frontline staff.  The staff fail to engage with the project which is eventually abandoned.


Positive: The team have a shared understanding of their work goals, use effective channels of communication and proactively manage conflict.  They demonstrate their commitment to collective learning by participating in multi-professional meetings to discuss and analyse patient safety incidents.

Negative: There is a lack of accountability within the team.  Patient safety issues are rarely raised or discussed and little or no collective learning happens

Communication & Training


Positive: Lay representatives are invited to attend board meetings.  They offer a unique patient perspective and make helpful suggestions practical ways in which safety can be improved.

Negative: Incomplete handovers and discharge summaries predispose to error and patient harm.


Positive: A district nurse administers effective CPR in a patient’s house when he stops breathing.  She attended a refresher life support course two months before the incident.

Negative: Staff members do not receive adequate training to use a new radiation therapy machine.  One of them selects the wrong mode, resulting in a radiation overdose to the patient.

Work Environment


Negative: Staff shortages increase a ward’s workload to the extent that the nursing staff cannot respond to a patient’s request for analgesia.  A formal complaint is made against the hospital a few days later.


Positive: Nurses wear tunics during their drug rounds to indicate that they should not be distracted.

Negative: A nurse accidentally dispenses the wrong drug during her round because of a distraction.

Physical environment

Negative: A nurse on night duty struggles to read the display of an infusion pump and accidentally administers an overdose.


Equipment design

Positive: An anaesthetist is able to stabilize a patient quickly on her first shift in a new theatre as a result of standardized and intuitive alarms and equipment.

Negative: Due to the similarity of two different syringes, a doctor accidentally administers the drug Vincristine intrathecally instead of intravenously.  The patient dies a few days later.

Process/task design

Positive: A surgical team routinely uses a checklist. In one case they detect that blood products are not available for a scheduled patient.  The error is rectified before the procedure.

Negative: A patient receives a wrong drug due to an overly complex drug prescribing system involving numerous steps.



Positive:  A cardiac surgeon successfully compensates for a rare anatomical variation during an arterial switch operation.

Negative: A registrar fails several times to apply a forceps to a baby’s head during a difficult delivery.  The case proceeds to a caesarean section.


Positive: A healthcare worker volunteers to do a favour for an elderly patient.

Negative: A doctor fails to comply with the hand hygiene protocols in spite of several requests from the nursing team.


Negative: A doctor finishing an extended A&E shift fails to notice that the left leg of an elderly patient with dementia is shortened and rotated. She is admitted to a medical ward and her femur fracture is only diagnosed three days later.


Negative: A health care worker takes sick leave after feeling bullied at work.